When Small Bandages Fail: The Field-Level Repair of Severe and Protracted Institutional Breaches

From situated repair to field-level repair

When an institution and its associated practices are enacted in everyday praxis, the agency of actors may give rise to situated improvisation and institutional variation as they ‘muddle through’ their everyday actions (Raaijmakers, Vermeulen, Meeus, & Zietsma, 2015, p. 88; Smets, Morris, & Greenwood, 2012). This may occur inadvertently (Smets & Jarzabkowski, 2013), or with more purposeful intent (Reay et al., 2006). Variations viewed as beneficial to participants, once honed through collective experimentation and reflexive theorization (Reay, Chreim, Golden-Biddle, Goodrick, Williams, Casebeer, Pablo, & Hinings, 2013), become embedded as a normal aspect of practice in that social context. Over time, they may be reinterpreted or redeployed to different arenas (Powell & Colyvas, 2008). But if the variation is perceived to breach one or more of the institution’s pillars, focally implicated actors undertake varying degrees of situated repair work in order to ‘mend’ the unfolding situation and maintain the institution (Ramirez, 2013, p. 865).

The form of repair enacted is contingent on the context, nature and process history of the breach. For breaches that are relatively minor, isolated events, repair work is commonly enacted through a process of ‘containment’ (Lok & de Rond, 2013, p. 197). Here, the actions constituting the breach are simply ignored or tolerated within actors’ reflexive normalization and negotiation work. However, as institutions are interpreted and reinforced through individual observation and experiential learning (Dacin et al., 2010), this minimal form of repair work may be perceived by actors to tacitly condone, and thus legitimize, institutional malpractice (Clark & Newell, 2013; Sminia, 2011).

A more effortful response to contain a minor breach is that of ‘custodial work’ (Dacin et al., 2010, p. 1407). In this form of situated repair, actors draw on social ‘censorship mechanisms’ to reinforce institutional expectations. This can occur through recourse to rules, normative role-based behaviours and authority structures, and culturally legitimate concepts and linguistic practices to maintain institutional arrangements (Bjerregaard & Nielsen, 2014, p. 986; Heaphy, 2013).

In more major breaches, where containment is untenable, situated repair work can be enacted through a process of ‘restoration’ (Lok & de Rond, 2013, p. 199). Here, once again, custodial work is undertaken through actors’ self-policing of rules, and self-corrective actions in relation to such rules, though now these actions may be supplemented by formal disciplining. During restoration, actors’ reflexive normalization work also centres on ‘excepting and co-opting’. These actions depict the breach as a ‘necessary, justifiable exception to a rule that still holds’, and that has arisen due to unforeseen extenuating circumstances (Lok & de Rond, 2013, p. 205).

Restoration work, complemented by negotiation work to reverse institutionally divergent decisions, enables an institutional template for action to be ‘temporarily stretched’ – through ‘institutional plasticity’ – so that breaches of institutional practices may be condoned without causing permanent structural change (Lok & de Rond, 2013, p. 205). This characterizes institutional pillars as mutually reinforcing and interconnected ‘elastic fibres’ and begs the question: what happens when they are stretched beyond the limits of their elastic tolerance (Hirsch, 1997; Hoffman, 1999; Scott, 2008, p. 49)?

Two studies have begun to explore this issue though empirical analysis of coercive policy reforms that fundamentally breached extant institutional arrangements. Currie et al. (2012, p. 958) show how elite professionals enacted institutional restoration, primarily through ‘theorizing’ and ‘defining’, to ‘re(generate) or re(create) institutional arrangements’ in a manner that enhanced, as opposed to simply maintained, elite professionals’ status. In the second study, Micelotta & Washington (2013) demonstrate how professionals reconstituted institutional arrangements by re-asserting the norms of interaction and re-establishing the balance of institutional powers. They therefore depict repair work as a maintenance function that enables the ‘disruption of institutional arrangements to be reversed and the status quo [ante] to be re-established’ (Micelotta & Washington, 2013, p. 1157).

Although these studies have clearly enriched our understanding of successful repair work, they have not illuminated cases where ‘small bandages’ have failed to address a ‘gaping wound’ in institutional arrangements (Clarke & Newell, 2013, p. 129). It is circumstances of this nature, which require field-level institutional repair work, that form the focus of our study.

We examine six of the most severe and protracted breaches of the institution of medicine in the English NHS; exemplified by the murder, sexual abuse, and untoward deaths of patients due to serious professional misconduct and gross neglect. In these breaches, following failed attempts at situated repair, field-level institutional repair work is enacted through UK Government inquiry reports. These challenge the undermined legitimacy of the institutionalized order and recommend changes to assuage societal concerns (House of Commons Public Administration Select Committee, 2005). Such field-level institutional repair work is, therefore, a rhetorical construct used to change the regulative, normative and cultural-cognitive pillars of the institution of medicine (Brown, 2004; Brown et al., 2012). Our study builds upon others who have examined the complex rhetorical argumentation strategies used to foster legitimation (and delegitimation) in active texts to challenge institutional arrangements (Brown et al., 2012; Erkama & Vaara, 2010; Green & Li, 2011; Harmon, Green, & Goodnight, 2015; Suddaby & Greenwood, 2005). We therefore ask: how is institutional repair work conducted at the field level?

The case studies

In the UK, the government, or one of its ministers, may institute a public inquiry or an independent private inquiry in the aftermath of a ‘precipitating event’: a natural disaster, major accident, policy failure or severe breach of institutionalized practice (Turner, 1976, p. 381). Typically, a severe breach involves failed attempts at situated repair resulting in the loss of implicated actors’ legitimacy and significant reputational damage to the field (Sulitzeanu-Kenan, 2010). Although not adversarial in nature, inquiries are inquisitorial in substance and form (Howe, 1999). Once instigated, an independent body is tasked to provide an impartial assessment of the facts. This activity provides scope to hold those responsible to account, thereby laying blame, while conveying politicized reassurance of repair to signify closure (Elliott & McGuinness, 2002; Walshe & Higgins, 2002).

A UK Government inquiry report sets out the ‘provenance claim’ of the inquiry – defining its commission, terms of reference, operative legislation, chair and assessors – and ‘comprehensiveness’ through an analysis of the nature of the severe breach (Brown, 2004, p. 100). These two aspects are complemented by rich description of the ‘internal workings’ of the organization under scrutiny that is punctuated by the testimonies of witnesses (Wicks, 2001, p. 670). Such reports provide an authoritative ‘meta-narrative’ of the actions of individuals and organizations involved in a severe breach (Brown & Jones, 2000, p. 658). Inquiry reports, therefore, represent a comprehensive repository of data and analyses, consolidated through targeted recommendations. They allow ‘little scope for disagreement’ and constitute part of the requisite processes of ‘cultural readjustment’ in the aftermath of a severe breach (Brown et al., 2012, p. 301; Turner, 1976, p. 378). Government inquiry reports, as external field-level evaluators, thus assert the ‘official position’ (Boudes & Laroche, 2009, p. 377; Bitektine & Haack, 2015), and function hegemonically to enact institutional repair work under their mask of ministerial authority (Brown, 2004; House of Commons Public Administration Select Committee, 2005).

As detailed case studies are required to examine institutional work (Currie et al., 2012; Lawrence et al., 2009), we employed a comparative case study design with government inquiry reports as our unit of analysis (Yin, 2009). This enabled a replication logic to be used in our within and cross-case analysis to confirm or disconfirm the inductive inferences we developed (Eisenhardt & Graebner, 2007). Emergent theory for such a research design is typically more generalizable and better grounded than theory from single-case studies, and may therefore be more amenable to extension and validation with other methods (Davis & Eisenhardt, 2011).

Following Currie et al. (2012), in selecting our cases we adopted a purposeful theoretical sample on the basis that each case may reveal similar or contrasting forms of rhetoric and institutional work for predictable reasons. For example, similarities arising from exogenous institutional forces in the medical policy or professional domains, and variations due to the nature of the severe breach, implicated focal actors, and local context. To ensure variation, the six cases selected for in-depth examination were ‘polar types’ (Eisenhardt, 1989; Eisenhardt & Graebner, 2007, p. 27). Each focused on a different severe breach of the institution of medicine, with three cases addressing the actions of isolated individuals, and the remainder wider departmental and organizational failings. Nonetheless, the selected cases were similar in two key aspects. First, each addressed a severe, and in some cases an extreme, breach of the institution of medicine that caused public, professional, and political loss of confidence in the English NHS. Second, the severity of each breach was compounded by their protracted nature, during which attempts at situated repair (of the forms described in previous studies) had not been successful. An outline of each case is presented in Table 1.

OPEN IN VIEWER

Table 1.

Government inquiries into severe and protracted breaches in the English NHS.

The Incompetent Surgeon
Breach	Mr Rodney Ledward was a consultant (a senior hospital-based medical specialist) in gynaecology and obstetrics at South Kent Hospitals NHS Trust. In 1998 he was found guilty of serious professional misconduct and struck off the Medical Register by the General Medical Council (GMC, the UK professional regulatory body for doctors), having been dismissed by the Trust in 1996. His serious breaches of the institution of medicine spanned the 16 year period from his appointment in 1980 until his dismissal, and included surgical incompetence, the removal of organs without securing informed consent, and providing misleading information to his patients to encourage them to opt for paid private treatment, as opposed to free NHS treatment, for his financial gain.
Inquiry	The inquiry into quality and practice within the NHS arising from the actions of Rodney Ledward (Ritchie, 2000)
	In 1999 the Secretary of State for Health set up an independent private inquiry into the quality of Ledward’s surgical practice within the NHS. The inquiry, chaired by Jean Ritchie Queen’s Council (QC), published its findings in one volume of 389 pages and forwarded 103 recommendations.
The Sexual Abusers
Breach	Dr William Kerr and Dr Michael Haslam were consultant psychiatrists at York Health Services NHS Trust. Kerr was appointed in 1965 and retired in 1988, while Haslam was appointed in 1970 and retired in 1999. In 2000 Kerr was convicted in his absence (due to dementia and memory loss) on a Trial of the Facts, pursuant to Section 4A of the Criminal Procedure (Insanity) Act 1964, of one count of indecent assault. The jury could not reach a decision on ten counts of indecent assault and two counts of rape. William Kerr was granted an absolute discharge and his name was placed upon the Sex Offenders Register. Haslam was convicted in 2003 of four counts of indecent assault – a conviction of rape was quashed on appeal – imprisoned for three years and his name was placed upon the Sex Offenders Register. Kerr and Haslam’s serious breaches of the institution of medicine, centred on the serial sexual abuse of female psychiatric patients, spanned 33 and 24 year periods, respectively. Both sought and were granted voluntary erasure from the Medical Register by the GMC, thereby avoiding professional disciplinary action.
Inquiry	The Kerr/Haslam inquiry (Pleming, 2005)
	In 2002 the Secretary of State for Health set up a modified form of private inquiry under Sections 2 and 84 of the NHS Act 1977 into Kerr and Haslam’s breaches of medical practice within the NHS. The inquiry, chaired by Nigel Pleming QC, published its findings in two volumes, totalling 955 pages, and forwarded 74 recommendations.
The Mass Murderer
Breach	Dr Harold Shipman was a general practitioner (a community-based primary care doctor) in Greater Manchester. In 2000 he was convicted of 15 counts of murder for which he was sentenced to 15 terms of life imprisonment. In addition, he was found guilty of forging the will of one of his murder victims, for his financial gain, and sentenced to a concurrent term of four years’ imprisonment. In January 2004 Harold Shipman committed suicide in Wakefield Prison. Shipman’s serious breaches of the institution of medicine spanned his career. They included the abuse and unlawful possession of opiate controlled drugs – diamorphine, morphine, and pethidine – which he administered by intravenous injection in lethal doses to his victims.
Inquiry	The Shipman Inquiry (Smith, 2002, 2003a, 2003b, 2004a, 2004b, 2005)
	In 2001, the Secretary of State for Health set up a public inquiry into Shipman’s medical practice within the NHS. The inquiry, chaired by Dame Janet Smith, ended in 2005 following the publication of six volumes, totalling 2654 pages, and forwarded 190 recommendations for improvement. The inquiry concluded that, in addition to the 15 patients of whose murder he was convicted, Shipman had murdered 200 patients, and may have been responsible for a further 45 deaths. Shipman is recognized as the UK’s most prolific serial killer.
The Failure of Medical Management
Breach	Serious breaches of the institution of medicine occurred at the United Bristol Healthcare NHS Trust (UBHT), specifically the Bristol Royal Infirmary (BRI), during the provision of cardiac surgical services for children born with congenital heart defects. In the period from 1991 to 1995, between 30 and 35 more children under one year old died after open-heart surgery in the BRI than might be expected had the paediatric cardiac surgery unit’s performance been typical of other units in England at the time. However, concerns were first raised in 1986. The GMC found Mr James Wisheart (Medical Director, UBHT and cardiothoracic surgeon) and Mr Janardan Dhasmana (Associate Clinical Director in Cardiac Surgery, UBHT, and cardiothoracic surgeon), and Dr John Roylance (Chief Executive, UBHT) guilty of serious professional misconduct. Roylance and Wisheart were erased from the Medical Register, while Dhasmana was made subject to condition that he did not operate on children.
Inquiry	The Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995: Learning from Bristol (Kennedy, 2001)
	In 1998 the Secretary of State for Health set up a public inquiry under Section 84 of the NHS Act 1977 into the medical management of the care of children receiving complex cardiac surgical services at the Bristol Royal Infirmary between 1984 and 1995. The inquiry, chaired by Professor Sir Ian Kennedy, published its findings in one volume of 530 pages and forwarded 198 recommendations.
The Illegal Removal and Retention of Body Parts
Breach	Serious breaches of the institution of medicine occurred at the Royal Liverpool Children’s Hospital, and focused on the removal, retention, and disposal of human tissue and organs from children after death without securing informed consent from their bereaved parents in contravention of the Human Tissue Act 1961.
Inquiry	The Royal Liverpool Children’s Inquiry (Redfern, 2001)
	In 1999 Lord Hunt, Parliament Under Secretary of State (Lords), established an independent confidential inquiry under Section 2 of NHS Act 1977 into Royal Liverpool Children’s Hospital’s compliance with the Human Tissue Act 1961 from 1962 to 1999, and aligned compliance with the Coroner’s Act 1988 and the Coroner’s Rules 1984. The inquiry, chaired by Michael Redfern QC, published its findings in one volume of 535 pages and forwarded 81 recommendations.
The Systemic Failure of Hospital Care
Breach	Serious breaches of institutionalized practice – medical, nursing, and healthcare management – at the Mid Staffordshire NHS Foundation Trust related to inadequate standards of healthcare provided across the organization. Critical reports by the Healthcare Commission and Department of Health reflected widespread public concern at the high mortality levels within the Trust, leading to a public loss of confidence in the Trust, its board, management, and clinical services.
Inquiry	Independent inquiry into the care provided by Mid Staffordshire NHS Foundation Trust January 2005-March 2009 (Francis, 2010) and the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis, 2013)
	In 2010 the Secretary of State for Health set up an independent inquiry into the standard of care provided from January 2005 to March 2009. The inquiry, chaired by Robert Francis, QC, published its findings in two volumes of 815 pages and forwarded 18 recommendations. Francis recommended that the Department of Health should consider an independent examination of the role of the commissioning, supervisory and regulatory bodies in the monitoring of Mid-Staffordshire NHS Foundation Trust. He was invited to undertake this inquiry, publishing a further three volumes in 2013, encompassing 1781 pages and 290 recommendations.

Data collection and analysis

We obtained all but one of the government inquiry reports from the UK Government’s National Archive (http://www.nationalarchives.gov.uk/webarchive/). The report into the Mid Staffordshire NHS Foundation Trust (Francis, 2010, 2013) was obtained from the inquiry website (http://www.midstaffspublicinquiry.com). As indicated in Table 1, collectively these reports consisted of 7659 pages of text and 954 recommendations. In essence, we took an iterative approach to theory building, moving between data and theory, involving both induction and deduction (Eisenhardt, 1989). This process was undertaken in overlapping phases, the most important of which are summarized below.

First, the government inquiry reports were read, and reread, to gain an understanding of each text. We then undertook a more detailed narrative analysis to discern how meaning was constructed with respect to the manifestation of each severe breach (Brown, 2004). We identified and abstracted summaries of the key explanatory arguments within each text. Each centred on the focal cause of the severe breach, and the reasons forwarded to explain why situated repair had failed following their disclosure. A complementary analysis of the accompanying recommendations was then undertaken to align them to each argument. In so doing, we sought to identify the theorization enacted by each text through ‘chains of cause and effect’ (Lawrence & Suddaby, 2006, p. 221).

To further refine our understanding of each text we identified and abstracted the discrete storylines and perspectives of different social actors (Boje, Luhman, & Baack, 1999; Boyce, 1995). These actors included the perpetrators, their supporters and critics, and patients as victims of the severe breaches. We sought to identify exemplars of ‘opposition’ embedded within each text, wherein ‘a storyteller can create a sense of what is right about something without ever talking about it, only by talking about what is wrong with its opposite’, focused on juxtapositional arguments of perceived acceptable and unacceptable medical practice (Feldman, Sköldberg, Brown, & Horner, 2004, p. 151). This helped to clarify how the need for repair was identified and communicated to promote learning and change in the English NHS (Rhodes & Brown, 2005).

Next, we examined the rhetorical strategies used in each text. This centred on the use of forensic rhetoric to explain the causes of the severe breaches, and the use of deliberative rhetoric in the recommendations (Aristotle, 1959; Corbett, 1999; Leach, 2000). We attributed rhetorical appeals to ethos, logos or pathos, consistent with other researchers in the field (Brown et al., 2012; Erkama & Vaara, 2010; Green, 2004; Suddaby & Greenwood, 2005). Rhetorical appeals were coded to ethos if they primarily served to build moral legitimacy through connections with judgements about the ‘character’ and ‘rightness’ of the repair work (Green, 2004; Green & Li, 2009). Appeals were coded to logos if they were rooted in pragmatic legitimacy (here, a desire for effective and efficient repair work) and concerned with the rational calculation of means and ends. Appeals were coded to pathos if they primarily served to construct pragmatic legitimacy through emotional justifications for the proposed repair work (Aristotle, 1959). The appeals were reviewed and, after deliberation and debate between the authors, consolidated to identify the key rhetorical argumentation strategies communicated in each text.

Finally, guided by Lawrence and Suddaby’s (2006) typology, each rhetorical appeal was analysed to identify the type of institutional work communicated and the institutional pillar targeted for repair. Our within and cross-case analysis was therefore based on the key rhetorical argumentation strategies and modes of institutional work enacted by each text (Eisenhardt, 1989).

Ethos

Our comparative case analysis identified two ethos argumentation strategies – incompetence and maleficence – which were used to explain the causes of the severe and protracted breaches of the institution of medicine in the English NHS. Each strategy was crafted through the skilful use of forensic rhetoric to underscore the ineptitude or malice of specific actors. Individual incompetence was asserted in the Incompetent Surgeon case and individual maleficence in the Sexual Abusers and the Mass Murderer cases. The remaining cases depicted collective incompetence. We therefore present a comparative account of the aforementioned cases to demonstrate the ethos appeals used to communicate incompetence and maleficence.

We illustrate how the government inquiry reports enacted one form of institutional work previously attributed to maintenance, demonizing (purposively deconstructing perpetrators’ professional medical identity), and one previously attributed to disruption, disassociation (of medical practice from the moral, ethical, and cultural sensibilities of the profession). Moreover, through the skilful use of opposition, adapted forms of creative institutional work deconstructed and delegitimated extant policing practices across normative medical management networks.

Logos

Our comparative case analysis identified one overarching logos argumentation strategy: the protection of the medical professional, and their profession, as opposed to the protection of patients. This strategy was used to augment the causal explanation of the severe breaches of the institution of medicine, and pass considered judgement on why situated repair had failed following their disclosure. This was communicated through the perpetrators’, and others’, defensive denial and abuse of hierarchical medical professional power, and compounded by the inadequate professional oversight of the quality of care. This logos appeal constituted the core of each inquiry report with the notable exception of the Mass Murderer case.

We illustrate how, through the skilful use of opposition, the government inquiry reports enacted one form of institutional work previously attributed to disruption, undermining assumptions and beliefs (of medical practice) to delegitimate medical professionals’ defensive institutional work and inadequate policing due to weak professional regulatory oversight and censure. Through such opposition, adapted forms of creative institutional work also deconstructed normative medical associations and networks. In addition, the reports enacted one form of institutional work previously attributed to maintenance, valorizing. Through this, an innovative form of situated repair, circumvention work, was also communicated.

Pathos

Our comparative case analysis identified shame as the overarching pathos argumentation strategy. This augmented the ethos and logos appeals to persuade the readers of each inquiry report of the need for field-level change to repair the severe and protracted breaches of the institution of medicine in the English NHS. Pathos appeals were value-based and conveyed in two distinct forms. In the Incompetent Surgeon, the Sexual Abusers, and the Systemic Failure of Hospital Care cases, anonymized catalogues of patients’ harm were used. But in the Mass Murderer, the Failure of Medical Management, and the Illegal Removal and Retention of Body Parts cases, detailed personal narratives of harm, typically centred on the death of a patient, communicated the impact of the severe breach upon the bereaved.

We demonstrate our findings through a comparative account of the pathos appeals conveyed in these groups of cases. We illustrate how, through the skilful use of opposition, the government inquiry reports enacted one form of institutional work previously attributed to disruption, disassociation, to reassert the moral, ethical, and cultural sensibilities of the profession of medicine.

Repairing individual and collective incompetence

Two logos argumentation strategies – individual appraisal and continuous professional development (CPD) – were recommended as the means to identify, repair, and prevent individual incompetence. However, these were supplemented by audit, performance monitoring and aligned corporate and clinical governance processes to correct and prevent collective incompetence. A culture of continuous improvement across the English NHS was therefore fostered by institutional maintenance work (policing, embedding and routinizing), and institutional creation work (education directed to the repair of normative standards of healthcare practice), and consolidated through regulatory change.

In the Incompetent Surgeon case, for example, the ‘annual appraisal’ of consultants was recommended to ‘assess their performance’, together with any ‘complaints and claims involving their work’. It was recommended that the medical director of each NHS Trust lead this development to embed and routinize this policing practice at the apex of the medical hierarchy. Although ultimate accountability for the knowledge, skills, and performance of doctors employed lay with the chief executive (Ritchie, 2000: Recommendations 27–31).

These logos appeals and types of institutional work were also reflected in the Failure of Medical Management, the Illegal Removal and Retention of Body Parts, and the Systemic Failure of Hospital Care cases, which addressed breaches of a collective nature. For example, in the Failure of Medical Management case, it was recommended that policing through individual performance appraisal become ‘compulsory for all healthcare professionals’, part of their ‘contract of employment’, and supplemented by ‘all healthcare employees’ engagement in ‘compulsory CPD’ (Kennedy, 2001: Recommendations 45, 82, 85). Moreover, such changes to normative practice were consolidated within new overarching regulatory frameworks for the individual revalidation and re-registration of health care professionals to ‘assure the competence of healthcare professionals’ (Francis, 2013: Recommendation 229; Kennedy, 2001: Recommendations 69, 88, 90).

In each case, the logos appeals sought to foster the policing of collective practice and performance through the embedding and routinizing of audit, performance monitoring and aligned governance processes across the English NHS. For example, despite the Incompetent Surgeon case addressing the focal acts of Ledward, the recommendations asserted that ‘all doctors, including consultants, must participate in clinical audit’, so that any ‘untoward events that have been recorded’ were to be openly ‘discussed and investigated’ to identify ‘how practice should be altered’. Again, each NHS Trust was tasked to appoint ‘a clinician to be the head of audit’ with this role to be accountable to the ‘clinical governance committee of the NHS Trust’ and ‘answerable directly to the chief executive’ (Ritchie, 2000: Recommendations 8, 10, 13).

Similarly, in the Failure of Medical Management case, audit was recommended as ‘compulsory for all healthcare professionals’, and was to be refined through the creation of ‘national standards of clinical care’ to facilitate the ‘monitoring of clinical performance at a national level’ (Kennedy, 2001: Recommendations 125–127, 143–147). Indeed, further refinement emerged in the Systemic Failure of Hospital Care case, wherein it was recommended that the ‘regulators of healthcare providers’ use their ‘own powers of intervention’ when concerns arose about organisational performance to ‘take whatever action within their powers [was] necessary to protect patient safety’ (Francis, 2013: Recommendations 31-32).

Repairing individual maleficence

The aforementioned logos argumentation strategies were reasserted in the Sexual Abusers and Mass Murderer cases, which sought to repair the maleficent acts of Kerr, Haslam, and Shipman. For example, in the Sexual Abusers case, the inquiry report recommended that the scope of healthcare professional appraisal be extended to encompass the ‘full range of physical, psychological and complementary therapies used’. The aim, here, was to better ensure the policing of ‘new or unorthodox treatments’ to prevent sexual abuse veiled by ‘fringe treatments’: a defence that had been used by Haslam (Pleming, 2005, p. 279: Recommendations 3–5). In addition, in these cases, the logos appeals recommended clarification of regulatory and normative standards of practice. Hence, adapted forms of institutional creation work were fostered to redefine regulations and reconstruct normative associations, especially with regard to the moral and cultural foundations of breached medical practices, each enabled through the re-education of healthcare professionals.

Furthermore, in the Mass Murderer case, redefinition of rules for ‘deaths which were, or might [have been], caused or contributed to by medical error or neglect’ were recommended, together with the requisite re-education of general practitioners in the appropriate use of the Coroner’s Service (Smith, 2003b: Recommendations 33–35). Similarly, it was reasserted that it was a ‘criminal offence for a doctor to prescribe a controlled drug for [themselves] or to self-administer a controlled drug’. This measure served to highlight extant rules in the Misuse of Drugs Act 1971 (Smith, 2004a: Recommendations 3, 4, 7). Nevertheless, in this case, an aligned ethos appeal tempered these recommendations by acknowledging that there was ‘little that would have deterred Shipman from killing’ as the institutional regulations, normative standards, and culture of medicine posed no impediment for a ‘serial killer’ (Smith, 2004b, pp. 15, 176).

Repairing individual and collective denial

In each case, a value-based ethos appeal sought to change the culture of individual and collective denial that pervaded the English NHS by valorizing openness. In the recommendations set out in the Incompetent Surgeon, the Sexual Abusers, and the Mass Murderer case, NHS staff were tasked to speak out once they realized that ‘something [had] gone wrong’. This was exemplified in the Incompetent Surgeon case by clear advocacy for ‘whistleblowing’ when confronted by the denial of others (Ritchie, 2000: Recommendations 19, 46). However, in the Sexual Abusers case, this recommendation was expanded in scope to enable ‘any person with a concern about the safety and effectiveness of the NHS’ to be allowed to voice their fears (Pleming, 2005: Recommendations 30–31). Change to the National Health Service (Complaints) Regulations was also recommended to facilitate such actions in general practice (Smith, 2004b: Recommendations 1–10).

Importantly, in the Failure of Medical Management case, this notion was redefined through a cogent ethos appeal that valorized the ‘duty of candour’ – defined as ‘a duty to tell a patient if adverse events have occurred’ – that was ‘owed by all those working in the NHS to patients’ (Kennedy, 2001: Recommendation 33). This was reiterated in subsequent inquiry reports, and embedded in the NHS Constitution to encourage the values of transparency and honesty in care (Francis, 2013: Recommendations 2, 178).

Our comparative case analysis identified two complementary logos argumentation strategies that were recommended to support the duty of candour and enhance patient safety: the redesign of the complaint procedure, and the development of systematic identification and reporting of adverse events. In these ways, institutional maintenance work through policing, embedding and routinizing, together with creation work through redesign and definition of systems were fostered by each inquiry report. Once again, repair work centred on normative standards of healthcare practice, consolidated through regulatory change, to foster a culture of continuous improvement across the English NHS.

In the Incompetent Surgeon case, for example, it was recommended that ‘patients who have concerns about their care must be able to raise the matter while they are in the hospital and be given a full and proper response at the time’. This sought to address patients’ ‘real fears’ that if they ‘question, challenge or complain’ about medical treatment when they are in hospital the care they received would be ‘adversely affected’ (Ritchie, 2000, pp. 188, 289: Recommendations 9, 15–27). Similarly, in the Sexual Abusers case, new policies and practices were recommended to ensure that psychiatric patients who raised ‘concerns or complaints in relation to allegations of abuse’ were not treated in ways that were ‘less favourable’. Given psychiatric patients’ vulnerability, it was recommended that ‘frontline staff’ were placed under the ‘express obligation to report’ the ‘suspicion of the abuse’ as opposed to a ‘formal complaint of abuse’ by a patient (Pleming, 2005: Recommendations 12, 33, 37).

This goal was further refined in the Failure of Medical Management case through the recommended introduction of ‘independent advocacy services’ for patients (Kennedy, 2001: Recommendation 36). Following the publication of Francis (2013), NHS Trust boards were tasked with the ‘coordinated collection of accurate information about performance’ – including ‘incidents, complaints and their investigations’ – which were to be made ‘available to providers, commissioners, regulators and the public’. Critically, in this regard, ‘to make or be party to a wilfully or recklessly false statement as to compliance with safety’ was positioned as a criminal offence (Francis, 2013: Recommendations 36–41).

In the second part of this logos appeal, the systematic identification and reporting of adverse ‘sentinel events’ was recommended to enhance patient safety (Kennedy, 2001: Recommendations 107–120). It was recommended that themes and trends arising from the data of ‘complaints, incidents, and patient and carer feedback’ should be analysed on a regular basis ‘to give early warning of emerging patterns of risk behaviour’ (Pleming, 2005: Recommendation 35). Again, heightened policing was recommended through the formation of new regulatory oversight bodies, to be ‘independent of government’, and to act in a co-ordinated manner to monitor the quality of care (Kennedy, 2001: Recommendations 39, 106–111). Finally, in the Systemic Failure of Hospital Care case, it was recommended that these regulatory bodies be consolidated to establish ‘a single regulator dealing both with corporate governance, financial competence, viability and compliance with patient safety and quality standards’ for all NHS Trusts to overcome barriers to communication and co-ordinate the quality and safety of care in the English NHS (Francis, 2013: Recommendation 19).

Repairing individual and collective abuse of professional power

In each case, a logos appeal sought to change the imbalance of power that had manifested through doctors’ abuse of patient consent. As a result, adapted institutional creation work was directed towards redefining normative practices concerning securing informed consent, and re-educating staff on its appropriate use. This precipitated normative, regulatory and cultural change across the English NHS.

In the Incompetent Surgeon case, guidance on ‘informed consent to surgery’ was recommended (Ritchie, 2000: Recommendation 91) and catalysed a debate that impacted the other cases. For example, in the Failure of Medical Management case, it was recommended that informed consent be considered as ‘a process and not a one-off event consisting of obtaining a patient’s signature on a form’ and ‘should apply not only to surgical procedures but to all clinical procedures and examinations which involve any form of touching’ (Kennedy, 2001: Recommendations 23–26). Furthermore, in the Illegal Removal and Retention of Body Parts case, the need for ‘strict compliance’ with the regulatory requirement to obtain ‘written consent’ before the retention of histopathology samples or organs as defined in the Human Tissue Act 1961 was reasserted. Amendment of this Act was also recommended to ‘provide a test of fully informed consent’, complemented by ‘training for all those involved in obtaining fully informed consent’ (Redfern, 2001: Recommendations 51–60).

The most notable challenge to the imbalance of power between healthcare professionals and patients was asserted in an ethos appeal in the Failure of Medical Management case. Here, the concept of ‘a patient-centred healthcare service’ was forwarded. This was underscored by ‘the notion of partnership’, whereby the ‘healthcare professional and the patient meet as equals with different expertise’. Moreover, it was recommended that the various bodies responsible for the regulation of healthcare professionals be tasked to ‘involve the public in their decision-making processes’, so that the collective voice of patients, consumers and citizens, would be focused toward the future ‘development and planning of healthcare services’, including the ‘regulation of safety and quality, the competence of healthcare professionals, and the protection of vulnerable groups’ (Kennedy, 2001: Recommendations 1–3, 157–166).

This value-based appeal was reaffirmed in the Systemic Failure of Hospital Care case through the recommendation that the ‘core values expressed in the NHS Constitution’; namely, that ‘all who work for [the English NHS] must adopt and demonstrate a shared culture in which the patient is the priority’, so that ‘everything done by the NHS and everyone associated with it should be informed by this ethos’ (Francis, 2013: Recommendations 2, 4–5).

Repairing inadequate professional oversight

In each case, the logos appeal built upon the recommendations illustrated above and sought to enhance the quality and safety of healthcare through redefinition of accepted normative standards of practice, the heightened policing of such practice, and a commitment to the provision of ongoing education of each professional group (Francis, 2010: Recommendation 4; Pleming, 2005: Recommendation 60; Ritchie, 2000: Recommendation 1; Smith, 2003b: Recommendation 37). However, it was recommended that in medicine, the culture of professional ‘mutual self-protection’ be brought to an end: ‘There can be no room today for the protection of colleagues where the safety and welfare of patients is at issue’ (Smith, 2004b, p. 23).

It was therefore recommended that the GMC still be tasked with defining the ‘ethics and the duties of a doctor’, advancing ‘good standards of medical practice’, and addressing ‘cases of professional misconduct’ (Ritchie, 2000: Recommendations 86, 101; Smith, 2004b: Recommendation 53). However, it was resolutely recommended that ‘the GMC’s primary role should be one, not of remediation of doctors, but of the protection of patients’, so that doctors who did not meet the required levels of performance would no longer be permitted to ‘limp on’ with ‘no real hope of meeting the standard’ and would be removed from practice in the English NHS (Smith, 2004b: Recommendation 94).